H1N1 Pandemic H1N1 Pandemic Influenza Planning Influenza Planning VideoconferenceVideoconference

August 24, 2009August 24, 2009

Purpose of the Purpose of the MeetingMeeting

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Pandemic FluPandemic FluH1N1H1N1

Terry L Dwelle MD MPHTM Terry L Dwelle MD MPHTM CPH FAAPCPH FAAP

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Pandemic Influenza – General Pandemic Influenza – General InformationInformation

Pandemic is a worldwide epidemicPandemic is a worldwide epidemicWe can expect several pandemics in We can expect several pandemics in

the 21the 21stst century century

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H1N1 (Swine Origin H1N1 (Swine Origin Influenza Virus)Influenza Virus)

33,902 cases in the US (estimate is that there have been 1 million 33,902 cases in the US (estimate is that there have been 1 million cases in the US) cases in the US)

3663 hospitalizations (10.8%, 0.36% of estimated cases in the US)3663 hospitalizations (10.8%, 0.36% of estimated cases in the US) 170 deaths (0.5% of identified cases and 4.6% of those hospitalized, 170 deaths (0.5% of identified cases and 4.6% of those hospitalized,

0.017% of estimated cases in the US)0.017% of estimated cases in the US) Genetically this H1N1 is linked to the 1918-19 strainGenetically this H1N1 is linked to the 1918-19 strain Currently we are seeing almost totally H1N1 circulatingCurrently we are seeing almost totally H1N1 circulating Majority of the cases are in children and young adultsMajority of the cases are in children and young adults Majority of hospitalized patients have underlying conditions (asthma Majority of hospitalized patients have underlying conditions (asthma

being the most common, others include chronic lung disease, DM, being the most common, others include chronic lung disease, DM, morbid obesity, neurocognitive problems in children and morbid obesity, neurocognitive problems in children and pregnancy).pregnancy).

There have been over 50 outbreaks in campsThere have been over 50 outbreaks in camps Southern hemisphere – currently seeing substantial disease from Southern hemisphere – currently seeing substantial disease from

H1N1 that is cocirculating with seasonal influenza. There has been H1N1 that is cocirculating with seasonal influenza. There has been some strain on the health systems in some situations.some strain on the health systems in some situations.

About 30% of infected individuals are asymptomatic (study from About 30% of infected individuals are asymptomatic (study from Peru)Peru)

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H1N1 in PregnancyH1N1 in PregnancyApril 15 to May 18, 2009 – 34 confirmed or April 15 to May 18, 2009 – 34 confirmed or

probable cases of H1N1 in pregnant probable cases of H1N1 in pregnant women reported to the CDCwomen reported to the CDC

11/34 (32%) were admitted to hospital11/34 (32%) were admitted to hospitalGeneral population hospitalization rate General population hospitalization rate

7.6%7.6%6 deaths – pneumonia and acute 6 deaths – pneumonia and acute

respiratory distress syndromerespiratory distress syndromePromptly treat pregnant women with Promptly treat pregnant women with

H1N1 infection with antiviralsH1N1 infection with antiviralsLancet on line, July 29, 2009

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Pandemic Influenza - ImpactPandemic Influenza - Impact

A moderate pandemic may exceed A moderate pandemic may exceed the capacity of hospitals to provide the capacity of hospitals to provide inpatient careinpatient care

Estimates of the Impact of an Influenza

1957 and 1957 and 19681968

19181918

Illness 90 million - 30% (160,000)

90 million - 30% (160,000)

Outpatient medical care

45 million - 50% (80,000)

45 million - 50% (80,000)

Hospitalization 865,000 (1600) – 1%

9, 900,000 (19,200) – 12%

ICU care 128,750 (256) – 0.16%

1,485,000 (2880) – 1.8%

Mechanical ventilation

64,875 (128) – 0.08%

745,500 (1488) – 0.93%

Deaths 209,000 (416) – 0.26%

1,903,000 (3840) – 2.4%

ND estimates in parentheses

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Pandemic Influenza - Pandemic Influenza - EpidemiologyEpidemiology

Pandemics occur in waves The order in which communities will be

affected will likely be erraticSome individuals will be asymptomatically

infectedA person is most infectious just prior to

symptom onset Influenza is likely spread most efficiently by

cough or sneeze droplets from an infected person to others within a 3 foot circumference

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Pandemic Influenza - Pandemic Influenza - ResponseResponseWe don’t look at pandemic flu as a

separate disease to be dealt with in a different way from regular seasonal influenza

Influenza response toolboxSocial distancing and infection control measureVaccineAntiviral medications

The most effective way to prevent mortality is by social distancing

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InterventionsInterventionsIntervention Decrease in Attack

Rates

Social distancing 72%

Social distancing + Antiviral treatment

72.6%

Social distancing + Antiviral treatment + Broad prophylaxis

75.6%

Proxemics of Influenza Proxemics of Influenza TransmissionTransmission

Elementary Schools

Hospitals

Offices

Residences

3.9 ft

7.8 ft11.7 ft

16.2 ft

Goals of Influenza PlanningGoals of Influenza Planning

Cases

Day

Goals•Delay outbreak peak•Decompress peak burden on hospitals and infrastructure•Diminish overall cases and health impacts

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IsolationIsolation From

www.cdc.gov/h1n1flu/guidance_homecare.htm

Data from 2009Most fevers lasted 2-4 days90% of household transmissions occurred within 5

days of onset of symptoms in the 1st caseRequires 3-5 days of isolation (different from the 7

days previously used for influenza). The rule here is isolation for 24 hours after resolution of the fever without the use of fever-reducing medications.

Consider closing a school or business for a minimum of 5 days which should move the infected into the area of much lower nasal shedding and contagion.

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Unstressed Hospital and Clinic Unstressed Hospital and Clinic Surge - North DakotaSurge - North Dakota

8.36

4.18

2.792.09

1.67

0

1

2

3

4

5

6

7

8

9

10 20 30 40 50

100% Cap

Hosp

/ ILI

Regional ILI rate

Clinic Caution 16.5

Clinic Crisis 21

X

1616

Pan Flu AntiviralsPan Flu Antivirals

Terry L Dwelle MD MPTHM Terry L Dwelle MD MPTHM CPH FAAPCPH FAAP

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Intervention - AntiviralsIntervention - Antivirals Antivirals (Tamiflu and Relenza) will be used Antivirals (Tamiflu and Relenza) will be used

primarily for treatment not prophylaxisprimarily for treatment not prophylaxisND will have approximately 160,000 treatment ND will have approximately 160,000 treatment

courses available for a pandemic (25% of the courses available for a pandemic (25% of the population)population)

Distribution flowDistribution flowNormalNormalNormal + Supplementation (from the state cache, Normal + Supplementation (from the state cache,

some prepositioned with LPHU’s) some prepositioned with LPHU’s) Points of DistributionPoints of Distribution

Resistance is a major concernResistance is a major concern

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Antiviral Treatment – H1N1Antiviral Treatment – H1N1

Sensitive to zanamivir (Relenza) and oseltamivir Sensitive to zanamivir (Relenza) and oseltamivir Tamilflu but resistant to amantadine and Tamilflu but resistant to amantadine and rimantadinerimantadine

Some circulating seasonal Influ A viruses may be Some circulating seasonal Influ A viruses may be resistant to oseltamivir – consider combination resistant to oseltamivir – consider combination treatment with oseltamivir and amantidine or treatment with oseltamivir and amantidine or rimantidinerimantidine

Uncomplicated febrile illness due to H1N1 does not Uncomplicated febrile illness due to H1N1 does not require treatmentrequire treatment

Treatment is recommended forTreatment is recommended for All hospitalized patients with confirmed, probable or All hospitalized patients with confirmed, probable or

suspected H1N1suspected H1N1 High risk patients for complicationsHigh risk patients for complications

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High risk groups for High risk groups for complicationscomplications

< 5yo (highest risk is < 2yo)< 5yo (highest risk is < 2yo) Adults Adults >> 65yo 65yo Persons with the following conditionsPersons with the following conditions

AsthmaAsthma Other chronic pulmonary diseasesOther chronic pulmonary diseases Cardiovascular disease (except hypertension)Cardiovascular disease (except hypertension) Renal, hepatic, hematological (including sickle cell disease), Renal, hepatic, hematological (including sickle cell disease),

neurologic, neuromuscular, metabolic (including diabetes neurologic, neuromuscular, metabolic (including diabetes mellitus)mellitus)

Immunosuppression including that caused by medication or Immunosuppression including that caused by medication or by HIVby HIV

Pregnant womenPregnant women < 19yo receiving long-term aspirin therapy< 19yo receiving long-term aspirin therapy Residents of nursing homes and other chronic care facilitiesResidents of nursing homes and other chronic care facilities

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Treatment guidanceTreatment guidance

Start treatment as soon as possible Start treatment as soon as possible after onset of symptoms after onset of symptoms Best if started before 48 hours from Sx Best if started before 48 hours from Sx

onsetonsetStill may be some benefit in Rx after 48 Still may be some benefit in Rx after 48

hourshoursDuration – 5 daysDuration – 5 daysDoses – H1N1 same as for seasonal fluDoses – H1N1 same as for seasonal flu

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Antiviral dosesAntiviral dosesMedication / GroupMedication / Group Rx for 5 daysRx for 5 days ChemoprophylaxisChemoprophylaxis

Oseltamivir (Tamiflu)Oseltamivir (Tamiflu)

AdultsAdults 75 mg bid75 mg bid 75 mg od75 mg od

ChildrenChildren << 15 kg 15 kg 30 mg bid 30 mg bid 30 mg od30 mg od

16-23 kg16-23 kg 45 mg bid45 mg bid 45 mg od45 mg od

24-40 kg24-40 kg 60 mg bid60 mg bid 60 mg od60 mg od

> 40 kg> 40 kg 75 mg bid75 mg bid 75 mg od75 mg od

Zanamivir (Relenza)Zanamivir (Relenza)

AdultsAdults Two 5 mg Two 5 mg inhalations bidinhalations bid

Two 5 mg Two 5 mg inhalations odinhalations od

ChildrenChildren Two 5 mg Two 5 mg inhalations bid (inhalations bid (>> 7 yo)7 yo)

Two 5 mg Two 5 mg inhalations od (inhalations od (>> 5 5 yo)yo)

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H1N1 Oseltamivir doses for < H1N1 Oseltamivir doses for < 1yo1yo

AgeAge Rx for 5 daysRx for 5 days ChemoprophylaxChemoprophylaxis for 10 daysis for 10 days

< 3 mo< 3 mo 12 mg bid12 mg bid Not Not recommended recommended unless criticalunless critical

3-5 mo3-5 mo 20 mg bid20 mg bid 20 mg od20 mg od

6-11 mo6-11 mo 25 mg bid25 mg bid 25 mg od25 mg od

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ProphylaxisProphylaxis

Close contact of cases (confirmed, Close contact of cases (confirmed, probable or suspected) who are at probable or suspected) who are at high-risk for complicationshigh-risk for complications

Health care personnel, public health Health care personnel, public health workers, or first responders who have workers, or first responders who have unprotected close contact to a case unprotected close contact to a case (confirmed, probable or suspect) (confirmed, probable or suspect) during the infectious period (24 hours during the infectious period (24 hours before to 24 hours after becoming before to 24 hours after becoming afebrile)afebrile)

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Close contactClose contact

Care for or live with a person who is a Care for or live with a person who is a confirmed, probable or suspect caseconfirmed, probable or suspect case

Having been in a setting where there is Having been in a setting where there is a high likelihood of contact with a high likelihood of contact with respiratory droplets and or other bodily respiratory droplets and or other bodily fluidsfluids

Activities like kissing, embracing, Activities like kissing, embracing, sharing of eating/drinking utensils, sharing of eating/drinking utensils, physical examination physical examination

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Pregnant womenPregnant women

Treatment – oseltamivir preferredTreatment – oseltamivir preferredProphylaxis – zanamivir Prophylaxis – zanamivir

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Prepositioning of Antivirals in the Prepositioning of Antivirals in the HomeHome

Relationship well established between the clinician Relationship well established between the clinician and patient or familyand patient or family

Medical history of all family members well known Medical history of all family members well known including medication allergies and underlying including medication allergies and underlying conditionsconditions

Compliance with physician instructions assuredCompliance with physician instructions assured Physician office capable of handling phone calls to Physician office capable of handling phone calls to

triage families / patients having antivirals in the triage families / patients having antivirals in the homehome

System to monitor expiration dates in placeSystem to monitor expiration dates in place Physician willing to accept liability for this practicePhysician willing to accept liability for this practice Patient willingness to pay for this medicationPatient willingness to pay for this medication

Vaccination StrategyVaccination Strategy

Molly Sander, MPHMolly Sander, MPH

Immunization Program Immunization Program ManagerManager

VaccineVaccineSeparate novel H1N1 influenza vaccine

from seasonal trivalent vaccine.45 million doses in mid-October

Followed be 20 million doses per week there after.

Five manufacturers: same age indications as seasonal vaccine.

Assume 2 doses required for everyone, separated by 3 to 4 weeks.

Remember to report any suspect vaccine adverse events to the NDDoH.

ACIP RecommendationsACIP RecommendationsPregnant women.Household contacts and caregivers

for children younger than 6 months of age.

Healthcare and emergency medical services personnel.

All people from 6 months through 24 years of age. Children from 6 months through 18 years

of age.Young adults 19 through 24 years of age.

ACIP RecommendationsACIP RecommendationsPersons aged 25 through 64 years who

have health conditions associated with higher risk of medical complications from influenza. Chronic pulmonary disease, including asthmaCardiovascular diseaseRenal, hepatic, neurological/neuromuscular, or

hematologic disordersImmunosuppresionMetabolic disorders, including diabetes mellitus

ACIP RecommendationsACIP Recommendations Once the demand for vaccine for the

prioritized groups has been met at the local level, programs and providers should also begin vaccinating everyone from the ages of 25 through 64 years.

Current studies indicate that the risk for infection among persons age 65 or older is less than the risk for younger age groups. However, once vaccine demand among younger age groups has been met, programs and providers should offer vaccination to people 65 or older. 

ACIP RecommendationsACIP RecommendationsIf demand exceeds supply:

pregnant women, people who live with or care for children

younger than 6 months of age, health care and emergency medical services

personnel with direct patient contact, children 6 months through 4 years of age,

and children 5 through 18 years of age who have

chronic medical conditions.

DistributionDistributionH1N1 vaccine purchased from

manufacturers by the federal government.

Vaccine is allocated to states based on population.

H1N1 vaccine will be distributed through a third party distributor (McKesson)Same distributor as Vaccines For Children

(VFC) vaccine.Will also ship ancillary supplies.

EnrollmentEnrollmentProviders are required to sign an Providers are required to sign an

enrollment form in order to receive enrollment form in order to receive H1N1 vaccine.H1N1 vaccine.CDC is creating a standardized form. CDC is creating a standardized form.

It is currently unavailable.It is currently unavailable.Enrollment requirements unknown, Enrollment requirements unknown,

but most likely include:but most likely include:Proper storage and handlingProper storage and handlingFollowing of ACIP recommendationsFollowing of ACIP recommendationsReporting of doses administered?Reporting of doses administered?

Administration FeeAdministration Fee The federal government will set a The federal government will set a

maximum administration fee.maximum administration fee.Most likely at the Most likely at the Medicare rateMedicare rate: $18.45/dose : $18.45/dose

in North Dakota. (Different than Medicaid fee in North Dakota. (Different than Medicaid fee cap for VFC:$13.90)cap for VFC:$13.90)

Administration fee may be billed to Administration fee may be billed to patient, Medicaid, Medicare, private patient, Medicaid, Medicare, private insurance, etc.insurance, etc.

Local public health units cannot refuse to Local public health units cannot refuse to vaccinate based on inability to pay.vaccinate based on inability to pay.Private providers will probably be able to Private providers will probably be able to

refuse vaccination if patient is unable to pay.refuse vaccination if patient is unable to pay.

NDIISNDIISThe North Dakota Immunization

Information System (NDIIS) will be used to track doses administered.Similar data entry to other vaccines, but

includes high-risk groups for vaccination.Doses administered must be reported to

CDC by the state on a weekly basis.Report each Tuesday for the previous week.

Contact the NDDoH at 701.328.3386 or toll-free at 800.472.2180 if interested in obtaining access.

Strategies for VaccinationStrategies for VaccinationCheck with local public health unit

to determine local strategies.Mass Immunization ClinicsSchool ClinicsVaccination similar to seasonal

influenza vaccination. (private and public mix)

Seasonal Influenza Seasonal Influenza VaccinationVaccination

May be started when vaccine is available.Immunity lasts for at least one year

according to CDC.ACIP recommendations published and

available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5808a1.htm?s_cid=rr5808a1_e. No changes from last season.

Some private vaccine has already shipped.

Pneumococcal VaccinationPneumococcal Vaccination The ACIP recommends that persons The ACIP recommends that persons

recommended for pneumococcal vaccine recommended for pneumococcal vaccine receive it in light of the potential for receive it in light of the potential for increased risk of pneumococcal disease increased risk of pneumococcal disease associated with influenza. associated with influenza.

There are at present no recommendations There are at present no recommendations to give pneumococcal vaccine to groups to give pneumococcal vaccine to groups for whom it is not currently recommended. for whom it is not currently recommended.

ACIP will revisit this question over the ACIP will revisit this question over the summer as epidemiologic data from the summer as epidemiologic data from the Southern hemisphere influenza season and Southern hemisphere influenza season and from the U.S. become available. from the U.S. become available.

Contact InformationContact Information

Molly Sander, MPH, Program Manager 328-4556

Abbi Pierce, MPH, Surveillance Coordinator 328-

3324 Keith LoMurray,

IIS Sentinel Site Coordinator 328-2404

Tatia Hardy, VFC Coordinator 328-2035 Kim Weis, MPH, AFIX Coordinator 328-2385

Community Community Mitigation and Mitigation and

Infection ControlInfection Control

Kirby Kruger, DirectorKirby Kruger, Director

Division of Disease ControlDivision of Disease Control

Community MitigationCommunity Mitigation

SchoolsSchoolsChildcare settingsChildcare settingsHealthcare settingsHealthcare settingsBusinessesBusinessesGeneral PublicGeneral PublicHome careHome care

Community MitigationCommunity Mitigation

Isolation or exclusionIsolation or exclusionVoluntary and passiveVoluntary and passive24 hours after fever subsides and not using fever 24 hours after fever subsides and not using fever

reducing medicationreducing medication

Hand hygieneHand hygieneRespiratory etiquetteRespiratory etiquette

Exclusion Period - time ill people Exclusion Period - time ill people should be away from othersshould be away from others

Applies to settings in which the Applies to settings in which the majority of the people are not at majority of the people are not at increased risk for complicationsincreased risk for complications

In general - for the general publicIn general - for the general publicDoes Does NOTNOT apply to health care settings apply to health care settings

StaffStaffVisitorsVisitors

Antivirals not considered with exclusionAntivirals not considered with exclusion

Infection ControlInfection ControlHealthcare FacilitiesHealthcare Facilities

CDC still recommending airborne CDC still recommending airborne precautionsprecautions (N95) with all (N95) with all encounters with patients with ILIencounters with patients with ILI

HICPACHICPACHas endorsed standard precautions plus Has endorsed standard precautions plus

droplet precautionsdroplet precautionsWHO – same as HICPACWHO – same as HICPACNDDoH Similar to HICPAC and WHONDDoH Similar to HICPAC and WHO

HomecareHomecare

Infection controlInfection control Drink plenty of clear fluidsDrink plenty of clear fluids OTC medications (no aspirin)OTC medications (no aspirin) Monitor fever and other symptomsMonitor fever and other symptoms When to seek medical careWhen to seek medical care

Difficulty breathing or chest painDifficulty breathing or chest painPurple or blue color in lipsPurple or blue color in lipsSevere vomiting Severe vomiting Signs of dehydration (dizzy, low urine output, no tears, Signs of dehydration (dizzy, low urine output, no tears,

loss of elasticity in skin)loss of elasticity in skin) Less responsive than usual or confusionLess responsive than usual or confusion

Infection Control in the Infection Control in the HomeHome

Place ill person in a private room try to designate one Place ill person in a private room try to designate one bathroom for ill personbathroom for ill person

Have ill person wear a surgical maskHave ill person wear a surgical mask No visitorsNo visitors One non-pregnant person should provide careOne non-pregnant person should provide care Caregiver should consider wearing maskCaregiver should consider wearing mask Caregiver should consider N95 if assisting with Caregiver should consider N95 if assisting with

respiratory treatmentrespiratory treatment Hand hygiene and respiratory etiquette for Hand hygiene and respiratory etiquette for

householdhousehold Use paper towels to dry handsUse paper towels to dry hands

Surveillance, Testing Surveillance, Testing and Reportingand Reporting

Kirby Kruger, State Kirby Kruger, State Epidemiologist, Division Epidemiologist, Division

DirectorDirector

of Disease Controlof Disease Control

What have we seen in ND?What have we seen in ND?

 

Laboratory SurveillanceLaboratory SurveillanceSentinel PhysiciansSentinel PhysiciansSyndromic SurveillanceSyndromic SurveillanceFollow-up of random sample of Follow-up of random sample of

children under the age of 18children under the age of 18School absenteeism reportsSchool absenteeism reportsOutbreak SupportOutbreak Support

SurveillanceSurveillance

HospitalizationsHospitalizationsWork with Infection Control NursesWork with Infection Control NursesParticipate in the Emerging Infections Participate in the Emerging Infections

ProgramProgramUse of RedBat to gather Hospitalization dataUse of RedBat to gather Hospitalization dataUse of HC StandardUse of HC Standard

School absenteeism ratesSchool absenteeism ratesIncrease the number of schools that reportIncrease the number of schools that reportMonitor school closuresMonitor school closures

SurveillanceSurveillance

Outbreak SupportOutbreak SupportIncrease the number of facilities that Increase the number of facilities that

can report outbreaks and receive free can report outbreaks and receive free testingtesting

SurveillanceSurveillance

TestingTesting

Limited testing in all areas of North Dakota Limited testing in all areas of North Dakota where novel H1N1 has not been where novel H1N1 has not been demonstrateddemonstratedTesting will be stopped once ongoing transmission is Testing will be stopped once ongoing transmission is

likely (2-5 positive tests)likely (2-5 positive tests)Current restriction on testing Current restriction on testing

• Ward, Cass and Burleigh CountiesWard, Cass and Burleigh Counties

All areas can continue to test for novel All areas can continue to test for novel H1N1 in hospitalized patients in which H1N1 in hospitalized patients in which H1N1 infection has not been ruled outH1N1 infection has not been ruled out

Rapid Testing - 1Rapid Testing - 1FrequencyRow PercentColumn Percent H1N1 Positive H1N1 Negative Total

Rapid A Positive

2153.8580.77

1846.1525.35

58

Rapid A Negative

58.6219.23

5391.3874.65

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Total 26 71 97*

Sensitivity = 80.77% Proportion of actual positives that were correctly identified.

Specificity = 74.65% Proportion of actual negatives that were correctly identified.

Rapid TestingRapid Testing

ResourcesResources

NDDoH flu web-page (updated every Wednesday)http://www.ndflu.com/

CDC flu web-pagehttp://www.cdc.gov/flu/http://www.cdc.gov/flu/

Questions and Questions and AnswersAnswers